My First Medication Error

To the nurse who just made their first medication error: I know what you’re feeling.

Your stomach is in your throat. Your eyes are burning with tears. Your heart is racing as you skim back through the MAR over and over again trying to figure out what could have gone wrong.

I know what you’re thinking

I’m a failure. I’m not a good nurse. This isn’t the right profession for me. I could have hurt my patient. What if something bad happens to my patient. What if I get fired. What if I lose my license. What if my reputation is ruined. What if I get yelled at. I should have checked one more time. I’m stupid. I’m worthless. I’m not ready to be a nurse.

Stop. Take a breath.

I remember my very first medication error. I was a new baby RN barely on my sea legs a few weeks after I turned 20.

The medication order: Azithromycin 500 mg IVPB every 24 hours

I gave Azithromycin 500 mg IVPB which is what my MAR prompted me to do when I came on night shift. Little did I know, the patient was transitioned from observation to acute care that afternoon. To do so, the patient was discharged from the observation visit and admitted under an acute visit. Azithromycin was already administered just hours before but the medications administered under the observation visit weren’t visible to me in the new acute chart. As the doctor put in orders (to be continued from the previous chart) it came up as DUE. A seasoned nurse would have looked back at the observation chart to make sure it wasn’t given twice. I was simply doing what my MAR prompted me to do without question. I didn’t ask WHY (rookie mistake in hindsight, but if you don’t know you should be looking for something, how do you know where to look?)

I didn’t even know I made an error at first. The two other nurses I was working with were acting strangely that night. There was a lot of whispering. Around 0400 they presented me with a neatly written and well thought out event report and explained they had written me up for my medication error HOURS after the IV medication had been infused.

I felt betrayed and confused and mortified. I felt like I was going to throw up. Were they talking about me all night? Why didn’t they tell me sooner when they noticed it? Do they think I’m a bad nurse bound to make a mistake? Why were they checking up on me to begin with? Is my patient going to be okay? I need to go see my patient. Does my patient know I’m a failure? Will they ask me to leave the room? Will they ask for a new nurse? How am I going to tell them I overdosed them on their antibiotic?

Rest assured, it all turned out just fine. My patient was fine. I sincerely question the way the medication error was brought to my attention but that’s a story for another day.

I had to tell the doctor. His response was, “Well, that isn’t what I intended but I guess we can’t change it now.” Whew.

I had to review the event thoroughly with my boss. He told me something I’ve repeated to my coworkers and nursing students time and time again.

Everyone. Makes. Medication. Errors. EVERYONE.

If you have never made a medication error, you will and you’ve likely not been in bedside nursing for very long or you’re straight up lying.

One more time for the people in the back, EVERYONE HAS OR WILL MAKE A MEDICATION ERROR.

Welcome to the club! It is almost a rite of passage!

Here’s the kicker you guys, YOU WILL MAKE ANOTHER MEDICATION ERROR.

Yup. That sucks doesn’t it. But that’s life. We are humans. We are not perfect and we will screw up again. The goal is not to make the same mistake twice. I can bet you won’t.

So, to the new nurse (or the old nurse) who just made their first medication error:

You are a good nurse. You are not a failure. You are cut out for nursing. You are learning. You will grow from this.

Stop. Take a deep breath. Take a minute. Take five minutes if you can. Show yourself some grace and read Friday’s blog post on the actual steps to take after a medication error.

3 thoughts on “My First Medication Error

  1. Kelsi Schroeder says:

    Nurses eating their young should be a future blog for ya. Gee wiz that’s not very cool on how they responded to the error. And if they knew the whole MAR deal then they probably should have taught that to you. Sounds like their system is just asking for mistakes. As someone who does chart reviews/QI review I would definitely think that your system failed you and that’s something that needs to be changed.

    On a side note. I know this wasn’t while I was working as a nurse, but my first medication error. Haha. My husband had some bowel issues and needed an Imodium. I went to the cupboard to get him one. Gave him what I thought was Imodium. However it was actually a laxative. I noticed it after he had already swallowed it and I had just put the container away. This may be terrible of me. But we both laughed about it then and we still laugh about it now.

  2. Louise K. says:

    I’m not a nurse, but did make a medication error….for my cat! The meds were a liquid painkiller (after teeth extraction), measured by an eyedropper in milliliters. I read the dosage wrong and gave her twice the dosage…for a few days. I was running out of meds too fast, re-read the dosage, and had to give her a bit less each time to make the meds last.
    I felt like a bad kitty mom, but she survived it just fine!
    Yes, we are all human. In the medical field, with everything charted, most mistakes come to light. In other types of work, I’m sure that some mistakes are never discovered.

  3. Carolyn Sullivan says:

    OH yeah I didn’t make one for years BUT it was ALL OK. and then many years later with more than 20 years under my belt I made another one!!!!
    BUT THEY should have come to you immediately behind your back write up was uncalled for…. NOT helpful.
    by the way the last mistake I made was giving an immunization. one was a powder to be mixed w liquid, and a second one was a liquid….. yes I mixed the powdered one in the other immunization!!!! I had to CALL THE MEDICAL DIRECTOR who was seeing pt at a different clinic that day! OH MY! THERE went my pride!

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